SEP-0816-2021 SEPTIC-DISPOSAL'PERMIT Office Use Only
APPLICATION Permit Mcc5 '�`� 16 - 2.p14
ITownftofCQym-.e.PsbW
Permit Fee:$
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Septic Variance? eNRevViiewed
Flood Zone? Y
Wetlands?- Y ; .
Project Location:-�� ���� �-�
IRE five
Tax Map #: �`� �It3�•
NOV 10 2021
ME-FIC "IFURVIAMENSW
Year Built Gallons #of bedrooms: - X gallons per =total daily flow TOWN OF�l�E A'1Qn,._
per day bedroom -far age under pis` es� No
1980 or older 150 nsta e . c oose no e) E
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature [,,Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? �--
Bedrock/Impervious material At what depth?
Domestic Water Supply KMunicipal ❑ Well ❑Lake
(if well or lake,.water supply from any septic system absorption is
ft.)
Percolation Test Rate: ! ,.per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size SP0 gallons (min. size 1;000 gallons, add 250 gallons-for each garbage cylinder or
spa/hot tub
System Absorption field W/#2 stone Total length ft.; Each Trench ft.
Seepage Pit w/#3 stone How many: • Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;
# of tanks
Septic Application Revised April2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
MailingAddres , C/S/': S°14�a•c�r '�
Cell Phone: SJ Land Line:
Email: S.
• Primary Owner(s):Lowe
Name(s):
Mailing Address, C/S/Z: '?. -IT iTonres
Cell Phone: Land Line: 4 04W
Email: 1"KeAV, Cc ,4. evv-.kr)\ I-SSOC-t S Co�.�,
❑ Check'if all work will be performed by property owner only
• Contractor.:
Contact Name(s): �r-r` Vvl, 5,e/ '
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
• Engineer(s):
Name(s):
Mailing Address, C
Cell Phone: Land Line:
E
Contact Person for Compliance in regards to this project:. 1 {,�! �
Cell Phone: C5_0(�TS-7 Land Line: '
Email:
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town approved electrical
inspection agency; 2. We will no_longer allow systems to be covered until such time as an as-built plan is
received and approved.The installed system must match the septic layout on file—no exceptions. 3. As-
built drawings must be submitted prior to the inspection, if there has been a change to the submitted
plans. 4. If, for any.reason, the building permit application is withdrawn, 30% of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
Declaration: Any permit or approval granted which is based upon or is granted in reliance upon any material-
representation or failure to make a material fact or circumstance known by or on behalf'of an applicant, shall be
void. I have read the regulations and agree to abide by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME:
SIGNATURE: DATE:
Septic Application Revised April 2021
TOWN OF OUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System. Checklist
Plan to scale
Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and
Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
N All wells on property and adjacent properties shown 00 C \Zh(
Water line shown Municipal or well 10'separation to any part of system
Setback to property lines show 10'or more for any part of system
Septic tank and pump stations 10' from foundation 50'from any well/lake/wetland 10'from any waterline
N Septic tank to foundation crawl space/slab on grade, grade in crawl space must be above top of septic tank
for 0',Separation required (field verification required)
,-(septic tank sized for s
Leech Field 20'from foundation 100'from any well 10'from water. line
Seepage pit 150'from well 50'from septic tank 1A"3 1--'sQ C—\V�"\
Seepage Pits-3-times diameter apart < ��
Septic tank and.pump stations over 30 gallons 50'from watercourse or wetland
1J Pdistance from bottom of trench or system 24"to bedrock or mottling 36"within 1000' of Lake George
`ONLeech field 100'-from watercourse or wetland
A)t-Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
Provide Engineer/Architect stamp for bed or design systems
Department of Health Approval for all mobile home park new systems Flood Plain requirements
2' above established flood elevation to bottom of system
0AII tanks anchored or 2' above flood elevation
Revised 4/15/2021
Google Maps 43'20'44.9"N 73-42-41.5"W
AS BUILT
FILF Cop,
Py
CO
24:
----------
Bonn(
Bonner Dr
Bonner Dr
Map data @2021 20 ft
295.10-1-70 SEP-0816-2021 S R
Laake TOWN OF QU
Keith
U S
F 10
Q
0
28 Bonner Dr G-) BUILDING & Q E
Reviewed B
Residential Septic Alteration Rev
TC"
Date: